Chemo for terminal cancer patients linked to aggressive care

NEW YORK (Reuters Health) - Terminally ill cancer patients
who received chemotherapy in the last months of life were more
likely to die in an intensive care unit than those who did not
receive chemo, according to a new study.

Many advanced cancer patients receive chemotherapy that is
only meant to make them more comfortable. They often don't
realize it will not cure them (see Reuters Health story of June
26, 2013 here: http://reut.rs/1hweUoA).

Holly G. Prigerson said that in her experience, "palliative
chemotherapy" often only makes patients sicker.

Prigerson worked on the new study at the Center for
End-of-Life Research of Weill Cornell Medical College in New
York City.

"This study arose from a bet I had with an oncology fellow
who had argued the benefits of palliative chemotherapy for the
dying patient," she told Reuters Health. "I was skeptical."

"Those who received palliative chemotherapy, even after
adjustment for their better health and quality of life and
treatment preferences at our baseline assessment, were worse
off," Prigerson said. "My oncologist colleague was surprised
because she was certain chemotherapy would be beneficial."

Those receiving chemo survived about as long - four months,
on average - as those who were not. But the circumstances of
their deaths were often different.

Fourteen percent of patients on chemotherapy had CPR or were
put on a mechanical ventilator, or both, in their last week of
life. That compared to two percent of people not on chemo.

Chemo users were more often referred to hospice at the last
minute: 54 percent were enrolled within one week of their death,
versus 37 percent of people not on chemo.

And 11 percent of chemo patients died in an intensive care
unit (ICU), rather than at home, for instance, compared again to
two percent of those not on chemotherapy, the researchers
reported in the British medical journal BMJ.

"It should be noted that these patients all had cancers that
had already worsened on one cancer treatment and therefore these
were particularly vulnerable patients," said Dr. Andrew S.
Epstein, a medical oncologist at Memorial Sloan Kettering Cancer
Center in New York City who was not involved in the research.

"Often these cancer treatments in this situation have more
risks than benefits, and this needs to be communicated better by
doctors and their teams," he said.

With better communication of the risks of chemo at such a
late stage, like those found in this study, many patients would
not choose it, he said.

Palliative chemo can have benefits for some patients,
shrinking tumors, reducing pain and improving quality of life,
said Dr. Thomas W. LeBlanc, a cancer and palliative care doctor
at Duke Cancer Institute in Durham, North Carolina.

"Like any tool, it must be applied very judiciously," he
said. "It does not yield benefits in cases where patients are
already significantly debilitated, or have markers of more
advanced, refractory disease. It is probably even harmful in
such settings."

But it can be very difficult for doctors to recognize
exactly the point when chemotherapy goes from being useful to
being harmful, said LeBlanc, who wasn't part of the research
team.

Patients who get palliative chemo are less likely to want to
talk about life expectancy or plan out a "do not resuscitate"
order compared to patients who do not, Prigerson said.

"They are more likely to want more aggressive care in
general, not make plans to avoid it, become critically ill,
possibly as a consequence of the chemo-induced toxicities and
then land in the ICU," she said.

"This study, along with other work done by this group, helps
paint a picture which suggests that many patients with
late-stage cancer are receiving aggressive medical care in ICUs
and chemotherapy at the end of their lives, even though this
care provides limited to no benefit, undermines their access to
care which might better control their symptoms, makes it less
likely that they will die in their preferred place of death and
is associated with worse overall outcomes for both patients and
caregivers," said Dr. Mark D. Siegel, co-chair of the Ethics
Committee at Yale-New Haven Hospital in Connecticut.

More work needs to be done exploring ways to foster care
that does a better job of treating symptoms and improving
quality of life for patients and caregivers, Siegel told Reuters
Health. He was not involved in the study.

"For patients to make informed choices of care, they need to
know if they are incurable and terminally ill, that
palliative chemotherapy is not intended to cure them, that it
may not appreciably prolong their life and that it may result in
the receipt of very aggressive life-prolonging care that may
sacrifice their quality of life," Prigerson said.